For years, hospital-based nurse externship programs have provided collaborative educational partnerships with schools of nursing allowing senior nursing students to safely practice under the supervision of a registered nurse (Tritak, Ross, Feldman, Paregoris, & Setti, 1997). Although originally intended to meet organizational recruitment and retention goals, the benefits of nurse externships were also quickly recognized (Starr & Conley, 2006). In times when many healthcare organizations are experiencing financial crises, nurse extern programs may be difficult to justify. To decrease the costs associated with an existing nurse extern program and show the benefits of the program to both nursing students and the organization, clinical nurse educators within a 23-hospital healthcare system collaborated to plan, implement, and evaluate a revised nurse extern program.
In the existing nurse extern program, the requirements and expectations were unclear to both nursing leaders and nurse externs, and there was an overall lack of structure. Nurse externs were recruited and hired throughout the year with no regard to future new graduate nurse hiring needs. Therefore, many externs who participated in the program ended up leaving the organization once the externship was completed as there were no new graduate nurse positions available. With no limit as to how many nurse externs were hired, no guarantee of placing a nurse extern into a new graduate nurse position, and no data to show the benefits of the program, nursing administration became concerned about the costs of the existing program.
PURPOSE
The purpose of revising the nurse extern program was to develop qualified, well-prepared new graduate nurses; evaluate the program cost; and evaluate the cost of nursing orientation and retention rates for new graduate nurses who worked as externs compared with new graduate nurses who did not work as externs at an inner city, Magnet-designated, 659-bed quaternary care medical center in the southwestern United States.
REVIEW OF THE LITERATURE
The benefits and successes of hospital-based nurse externship programs to help prepare nursing students for clinical practice have been well established (Hughes, Cummings, & Allen, 1993; Starr & Conley, 2006; Tritak et al., 1997). However, the literature is absent of descriptions of the financial impact of nurse externships on a healthcare organization. In today's economic environment, hospital administrators may view nurse externship programs as an increased financial burden, yet nurse managers continue to express concerns that new graduate nurses lack the preparation necessary to function (Berkow, Virkstis, Stewart, & Conway, 2009). Recent evidence (Lott, Willis, & Lyttle, 2011) confirms the ongoing benefits of nurse externship programs to meet the needs of both nurse managers and new graduates; however, these findings can be easily overlooked during times of increasing financial strain. Findings need to be disseminated so that the financial fear of nurse externships may be replaced with a renewed sense for why these programs were originally implemented.
Planning the Revised Nurse Extern Program
Similar to the work by Lott et al. (2011), a Nurse Extern Task Force was created to reenergize the nurse extern program. The task force was led by the Director of Nursing Clinical Academic Programs and consisted of the program manager for the Student Center of Excellence, two nursing recruiters, and clinical nurse educators from various facilities within the system. Once it was agreed upon by all the facilities in the system that a nurse extern program could still be beneficial, the task force proceeded to focus on the concerns from the original nurse extern program.
Addressing Financial Constraints
Each facility agreed to decide, based on hiring needs, whether it wanted the extern program to run continuously or intermittently. If continuous, the number of nurse externs would then be determined based on the hiring needs and budget of that particular facility. Guidelines were developed for nursing leaders. The number of nurse externs to be hired was also decreased, and nurse externs in the new program had to be within 6 months of graduation from nursing school and able to work one to two 12-hour shifts per pay period over the course of the 6 months with an assigned RN preceptor.
Addressing Program Management and Nurse Extern Expectations
Each facility designated one clinical educator to be responsible for the oversight of the program to ensure that the expectations and requirements of the program would be communicated consistently to the nurse externs, managers, unit-based educators, preceptors, and nursing staff. It was also communicated that, if expectations were not met or if a nurse extern was not progressing, he or she would be held to the same standards as any other employee. The clinical educator would coordinate monthly evaluations between the nurse extern and preceptor and share those evaluations with the nurse manager and unit-based educator so everyone would be aware of the nurse extern's progress. In addition, the nurse externs would be required to establish goals with the preceptor and submit reflective journals about their experiences. Although the clinical educator would be responsible for maintaining the information, there would also be an option to place copies in the nurse externs' personnel files if the manager requested. Finally, a new guideline was developed requiring that nurse externs must sit for, and pass, the NCLEX-RN within 45 days of graduation if offered a new graduate RN position.
The planning and development stages took place in 2009 and were finished in early 2010. After approval from the chief nursing officers, the clinical nurse educator responsible for the oversight of the nurse extern program at one of the larger facilities in the southwestern United States presented the new program to the nursing leadership team at the facility. Although there was some concern that the new program would result in the same outcomes as before, nurse managers with anticipated hiring needs agreed to hire nurse externs.
IMPLEMENTATION
In March 2010, the chief nursing officer at one institution that was part of the healthcare system approved 10 vacancies for nurse externs in the medical/surgical and progressive care units. After the first cohort of 10 nurse externs started in June 2010, additional cohorts started in December 2010 (14 nurse externs) and July 2011 (12 nurse externs). Preference was given to nursing students in baccalaureate nursing (BSN) programs, system-sponsored nursing programs, and nursing students who were employees of the medical center. Starting with the second cohort, nurse externs were also placed in critical care units in addition to the medical/surgical and progressive care units. For the third cohort, only BSN students were considered to align with the Institute of Medicine's recommendation to increase the number of BSN-educated nurses (Institute of Medicine, 2010).
Nurse Extern Orientation
Upon hire, all nurse externs went through the medical center's new employee orientation, clinical nursing orientation, nurse extern orientation, and electronic medical record class before starting the first 12-hour shift with the assigned RN preceptor. During the brief extern orientation, nurse externs were presented with the purpose of the program, the nurse extern job description and scope of practice, and the program requirements and expectations. Each preceptor, nurse manager, and unit-based nurse educator involved with the nurse extern program also received information detailing the role and scope of practice of nurse externs and the program requirements and expectations.
Extern Program Coordination
Once the nurse externs began working with the assigned RN preceptors, the clinical educator overseeing the nurse extern program began monitoring each extern's progress. Work hours were tracked to ensure minimum requirements were met and hours were not over budget, monthly evaluations were coordinated between the externs and RN preceptors, reflective journals were collected, and each extern received a follow-up at 3 and 6 months to ensure all program evaluations were completed. Although the clinical educator remained the primary contact for nurse externs throughout the program, the externs were encouraged to use unit educators and clinical managers as resources as well to promote a sense of belonging to the assigned units. The RN preceptors were instructed to contact the extern coordinator, unit nurse educator, or manager if there were any issues or concerns that needed to be addressed. Four or five months into the program, nurse externs were instructed to meet with nurse managers to discuss applying for new graduate nurse positions on their assigned units. The extern coordinator facilitated communication between the nurse managers and nurse recruiters to ensure that the nurse externs were considered top priority for any new graduate nurse positions.
EVALUATION AND OUTCOMES
Evaluation data were obtained throughout the program and included the nurse externs' self-evaluations at the beginning and end of the program and a program evaluation at the middle and end of the program. The self-evaluations contained statements using a 1-4 Likert scale to obtain feedback about the externs' organizational skills, assessment skills, knowledge, clinical decision making, communication, documentation, procedural bedside skills, teamwork, stress management, and professional development. The program evaluations contained statements using a 1-5 Likert scale to obtain feedback about the externs' orientation to their position, quality of their experience, and ability to care for a patient on the unit. The program evaluations also asked nurse externs if the management team facilitated an environment for success, if the program was individualized to meet their learning needs, and if there was adequate time for precepted experiences. Nurse externs improved in all areas of the self-evaluation from the beginning to the end of the program with the most improvement in the "assessment skills" and "knowledge" scores (see Table 1). Scores from the mid- and end program evaluations remained fairly equal except for the "ability to care for the average patient in your unit" score, which increased from an average score of 3.7 to 4.5 (see Table 2). One central question asked to all of the nurse externs at the middle and end points of the program was "In what ways has the extern program facilitated your learning?" Many nurse externs believed that working as an extern "allowed experiences that school clinicals could not provide," and the majority believed that such experiences helped develop their communication and prioritization skills. Externs also expressed feeling more prepared to make the transition to the role of new graduate nurse because of their participation in the program. One extern stated: "I can't even imagine starting a job as a new graduate nurse without first having this experience."
For the reflective journals, nurse externs were instructed to "write about your day at the end of your shift" and were not given any specific journaling guidelines or topics. The nurse externs were specifically instructed to complete the reflective journals while they were still at the hospital. Journals were then e-mailed to the extern coordinator. Similar comments to those on the mid- and end program evaluations were found in the reflective journals, and common themes emerged (see Table 3).
Data related to the cost of the nurse extern program, the conversion rates of extern to RN, the hours and costs of nursing orientation for new graduate nurses who were in the extern program, and the retention rates for new graduate nurses who were in the extern program were collected. Data were collected after the externs had graduated from nursing school, were hired into an RN position within the healthcare system, and had completed their nursing orientation. The postexternship data were then compared with a group of new graduate nurses who had not been in the extern program. Retention data of new graduate nurses who were externs and new graduate nurses who were not externs were examined from November 2010, when the first extern was hired as an RN, through February 2012.
DISCUSSION
On the basis of the data from the nurse extern self-evaluations, program evaluations, and reflective journals, along with the financial and retention rate data, the outcomes of the redesigned program were achieved. Reducing the number of externs hired from nearly 100 to 36 is an obvious cost-savings measure. However, by also comparing the performance, cost-savings, and retention rates of new graduate nurses who were externs to new graduate nurses who were not externs, further data suggest that a nurse extern program may not be much of a financial burden. Also, the increased preparedness of new graduate nurses who were externs confirms the benefits of a nurse extern program for new graduate nurses. Finally, the data also reflect the financial benefits to the organization in terms of retention rates and costs of orienting new graduate nurses who participated in the nurse extern program.
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